Citation Nr: 18147174 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 15-04 255A DATE: November 2, 2018 ORDER Entitlement to a rating in excess of 70 percent effective December 10, 2009, for an adjustment disorder with anxious mood and posttraumatic stress disorder (PTSD) with memory loss is denied. Entitlement to a rating in excess of 20 percent effective December 10, 2009, for diabetes mellitus with erectile dysfunction is denied. Entitlement to a rating in excess of 10 percent effective December 10, 2009, for left knee laxity is denied. Entitlement to a rating in excess of 10 percent effective December 10, 2009, for left knee iliotibial band syndrome (previously claimed as bilateral chondromalacia with degenerative osteoarthritis) is denied. Entitlement to a rating in excess of 10 percent effective December 10, 2009, for right knee strain (previously claimed as bilateral chondromalacia with degenerative osteoarthritis) is denied. Entitlement to a rating in excess of 10 percent effective December 10, 2009, for right ankle strain is denied. Entitlement to a rating in excess of 10 percent effective December 10, 2009, for left ankle strain is denied. Entitlement to a rating of 20 percent effective December 10, 2009, for lumbosacral strain is granted. Entitlement to a compensable rating effective December 10, 2009, for hypertension is denied. Entitlement to a rating in excess of 20 percent effective December 10, 2009, for left shoulder status post sprain is denied. New and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for right leg radiculopathy. New and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for left foot pain. New and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for bilateral fallen arches. New and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for right wrist sprain. New and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for sinusitis. New and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for refractive error. New and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for post-circumcision residuals. New and material evidence has not been received to reopen the Veteran’s claim of entitlement to service connection for left elbow pain. New and material evidence has not been received to reopen the Veteran’s claim of entitlement to service connection for bilateral shin splints. Entitlement to service connection for right wrist sprain is denied. Entitlement to service connection for sinusitis is denied. Entitlement to service connection for refractive error is denied. Entitlement to service connection for left ear hearing loss is denied. Entitlement to service connection for a right foot condition is denied. Entitlement to service connection for a bladder condition is denied. Entitlement to service connection for a stomach condition is denied. Entitlement to service connection for left leg radiculopathy is granted. Entitlement to service connection for sleep apnea is denied. REMANDED The issue of entitlement to a rating in excess of 10 percent effective December 10, 2009, for left middle finger fracture is remanded. The issue of entitlement to service connection for right leg radiculopathy is remanded. The issue of entitlement to service connection for bilateral fallen arches is remanded. The issue of entitlement to service connection for post circumcision residuals is remanded. The issue of entitlement to service connection for left foot pain is remanded. The issue of entitlement to service connection for right shoulder condition is remanded. The issue of entitlement to service connection for a left pinky condition is remanded. FINDINGS OF FACT 1. During the period on appeal, the Veteran’s psychiatric disorder characterized as an adjustment disorder with anxious mood and PTSD has manifest by no more than symptoms such as suicidal ideation, disturbed mood and concentration, appetite reduction, weight loss, avoidance of social situations, ongoing marital problems, and feelings of worthlessness. 2. During the period on appeal, the Veteran’s diabetes mellitus has been characterized by no more than following a restricted diet, no restricted activities, and taking insulin before meals. 3. During the period on appeal, the Veteran’s left knee laxity has been characterized by no more than minimal laxity with normal gait and posture. 4. During the period on appeal, the Veteran’s left knee iliotibial band syndrome has been characterized by no more than pain with motion and range of motion measurements including flexion from 0 to 115 degrees and extension of 0 degrees. 5. During the period on appeal, the Veteran’s right knee strain has been characterized by no more than pain with motion and range of motion measurements including flexion from 0 to 110 degrees and extension of 0 degrees. 6. During the period on appeal, the Veteran’s right ankle strain has been characterized by no more than range of motion measurements including dorsiflexion from 0 to 10 degrees and plantar flexion from 0 to 35 degrees. 7. During the period on appeal, the Veteran’s left ankle strain has been characterized by no more than tenderness and range of motion measurements including dorsiflexion from 0 to 10 degrees and plantar flexion from 0 to 35 degrees. 8. During the period on appeal, the Veteran’s lumbosacral strain has been characterized by no more than pain radiating to his upper back, avoidance of lifting heavy objects, and range of motion measurements including flexion from 0 to 45 degrees, extension from 0 to 20 degrees, right lateral flexion from 0 to 25 degrees, left lateral flexion from 0 to 15 degrees, right lateral rotation from 0 to 40 degrees, and left lateral rotation from 0 to 35 degrees. 9. During the period on appeal, the Veteran’s hypertension has been characterized by no more than blood pressure readings with systolic pressure predominately below 160 and diastolic pressure predominately below 100. 10. During the period on appeal, the Veteran’s left shoulder, status post sprain has been characterized by no more than inability to lift his left arm above shoulder level during flare-ups. 11. In September 2003, VA denied service connection for right leg radiculopathy. The Veteran was informed in writing of the adverse determination and his appellate rights in September 2003. He did not submit a notice of disagreement (NOD) with the decision. 12. The September 2003 rating decision is final. 13. Evidence associated with the claims file since the September 2003 rating decision is new and material and raises a reasonable possibility of substantiating the Veteran’s claim. 14. In June 1999, VA denied service connection for left foot pain, bilateral fallen arches, right wrist sprain, left elbow pain, sinusitis, bilateral shin splints, refractive error, and post circumcision residuals. The Veteran was informed in writing of the adverse determinations and his appellate rights in June 1999. He did not submit a notice of disagreement (NOD) with the decision. 15. The June 1999 rating decision is final. 16. Evidence associated with the claims file since the June 1999 rating decision is new and material and raises a reasonable possibility of substantiating the Veteran’s claims of service connection for left foot pain, bilateral fallen arches, right wrist sprain, sinusitis, refractive error, and post circumcision residuals. 17. Evidence associated with the claims file since the June 1999 rating decision does not raise a reasonable possibility of substantiating the Veteran’s claims of service connection for left elbow pain and bilateral shin splints. 18. Right wrist sprain did not originate during active service. 19. Sinusitis did not originate during active service. 20. Refractive error is a congenital disorder and was not aggravated during active service. 21. Left ear hearing loss did not originate during active service. 22. A right foot condition did not originate during active service. 23. A bladder condition did not originate during active service. 24. A stomach condition did not originate during active service. 25. Left leg radiculopathy originated during active service. 26. Sleep apnea did not originate during active service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent, effective December 10, 2009, for a psychiatric disorder characterized as an adjustment disorder with anxious mood and PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.14, 4.21, 4.130, Diagnostic Code 9440 (2017). 2. The criteria for a rating in excess than 20 percent, effective December 10, 2009 for diabetes have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.321, 3.327, 4.1, 4.2, 4.3, 4.7, 4.21, 4.119, Diagnostic Code 7913 (2017). 3. The criteria for a rating in excess of 10 percent, effective December 10, 2009, for left knee laxity have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2017). 4. The criteria for a rating in excess of 10 percent, effective December 10, 2009, for left knee iliotibial band syndrome have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003, 5260 (2017). 5. The criteria for a rating in excess of 10 percent, effective December 10, 2009, for right knee strain have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003, 5260 (2017). 6. The criteria for a rating in excess of 10 percent, effective December 10, 2009, for right ankle strain have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 7. The criteria for a rating in excess of 10 percent, effective December 10, 2009, for left ankle strain have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 8. The criteria for a rating of 20 percent, effective December 10, 2009, for lumbosacral strain have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5237 (2017). 9. The criteria for a compensable rating, effective December 10, 2009, for hypertension have not been met. 38 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 7101 (2017). 10. The criteria for a rating in excess of 20 percent, effective December 10, 2009 for left shoulder status post strain have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2017). 11. The September 2003 rating decision that denied service connection for right leg radiculopathy is final. 38 U.S.C. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2017). 12. New and material evidence sufficient to reopen the Veteran’s claim for right leg radiculopathy has been presented. 38 U.S.C. §§ 5103, 5103A, 5107, 5108 (West 2014); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2017). 13. The June 1999 rating decision that denied service connection for left foot pain, bilateral fallen arches, right wrist sprain, left elbow pain, sinusitis, bilateral shin splints, refractive error, and post circumcision residuals is final. 38 U.S.C. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2017). 14. New and material evidence sufficient to reopen the Veteran’s claims for service connection for left foot pain, bilateral fallen arches, bilateral fallen arches, right wrist sprain, sinusitis, refractive error, and post circumcision residuals has been presented. 38 U.S.C. §§ 5103, 5103A, 5107, 5108 (West 2014); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2017). 15. New and material evidence sufficient to reopen the Veteran’s claims for service connection for left elbow pain and bilateral shin splints has not been presented. 38 U.S.C. §§ 5103, 5103A, 5107, 5108 (West 2014); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2017). 16. The criteria to establish service connection for right wrist sprain have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 17. The criteria to establish service connection for sinusitis have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 18. The criteria to establish service connection for aggravation of refractive error have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 19. The criteria to establish service connection for left ear hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 20. The criteria to establish service connection for a right foot condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 21. The criteria to establish service connection for a bladder condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 22. The criteria to establish service connection for a stomach condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 23. The criteria to establish service connection for left leg radiculopathy have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 24. The criteria to establish service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1986 to August 1986; December 1987 to December 1997; February 2008 to July 2008; and December 2008 to December 2009. Effective July 2012, the Veteran’s combined service-connected evaluation is 100 percent. Effective December 2009, the Veteran is in receipt of special monthly compensation on account of loss of use of a creative organ. Increased Ratings Disability evaluations are determined by comparing the Veteran’s current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). 1. Entitlement to a rating in excess of 70 percent effective December 10, 2009, for an adjustment disorder with anxious mood and posttraumatic stress disorder (PTSD) with memory loss The Veteran’s mental disorder is presently evaluated as 70 percent under Diagnostic Code 9440 as chronic adjustment disorder. The Board notes that PTSD and chronic adjustment disorder are rated using the same criteria and therefore the Board has not changed the phrasing of the issue to maintain consistency and clarity with previous Regional Office decisions. A 70 percent evaluation requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work like setting), and an inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9440 (2017). A 100 percent evaluation requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant’s social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran was seen multiple times with complaints of depression, sleeplessness, and other psychiatric symptoms from July 2010 to August 2010. In an August 2010 treatment note, the Veteran was seen with concerns regarding sleep difficulties due to intrusive nightmares, night sweats, and nighttime enuresis (bed wetting). The Veteran also noted disturbed mood and concentration, appetite reduction, weight loss, and avoidance of social situations. The Veteran noted difficulty finding employment and eviction from his last residence due to an inability to pay rent. The Veteran denied present suicidal or homicidal ideation but noted a history of suicidal ideation over the preceding month. The examiner noted additional symptoms including depressed mood, diminished interest in activities, fatigue, poor concentration, and feelings of worthlessness. In an examination received by the VA in December 2010, the Veteran was noted to have no psychiatric symptoms including no depression, trouble sleeping, nervous trouble, memory loss, or suicide attempts. In June 2011, the Veteran was afforded an examination. The Veteran reported symptoms including irritability, sleep disturbance, ongoing marital problems, and poor sexual function. The examiner noted additional past symptoms of memory problems and insomnia. The Veteran noted that he can sense bad situations almost before they happen and reported a history of vague visual hallucinations in the early 1990s with no recent occurrences. However, the Veteran also denied auditory and visual hallucinations. The Veteran reported occasional suicidal thoughts without plan or intent. During the period on appeal, the Veteran’s PTSD has been characterized by no more than symptoms such as suicidal ideation, disturbed mood and concentration, appetite reduction, weight loss, avoidance of social situations, ongoing marital problems, and feelings of worthlessness. The preponderance of the evidence is against the claim for an increased rating. A 100 percent rating is not warranted under Diagnostic Code 9440 because the Veteran is not exhibiting disorientation as to time or place, or the intermittent inability to perform activities of daily living, including maintenance of personal hygiene. The Veteran’s suicidal thoughts have not risen to a persistent danger to himself and he has not manifested a persistent danger to others. 2. Entitlement to a rating in excess of 20 percent effective December 10, 2009, for diabetes mellitus with erectile dysfunction The Veteran’s diabetes mellitus has been rated under Diagnostic Code 7913. 38 C.F.R. § 4.119. Diagnostic Code 7913 provides that requiring insulin and restricted diet; or oral hypoglycemic agent and restricted diet is rated 20 percent disabling. Requiring insulin, restricted diet, and regulation of activities is rated 40 percent disabling. Requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated is rated 60 percent disabling. Requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated is rated a maximum 100 percent disabling. The rating criteria for diabetes are successive. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007). Successive criteria exist where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). The term “regulation of activities” is specifically defined as “avoidance of strenuous occupational and recreational activities.” Camacho v. Nicholson, 21 Vet. App. at 363. Medical evidence is required to support this criterion; a medical provider must indicate that the claimant's “diabetes is of such severity that he should curtail his activities such as to avoid strenuous activity.” Id. at 364. Although VA regulations under 38 C.F.R. §§ 4.7, 4.21 generally provide that symptoms need only more nearly approximate the criteria for a higher rating to warrant such a rating, those regulations do not apply where the rating schedule establishes successive criteria. Complications of diabetes mellitus are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). Here, the Board notes that the Veteran’s service-connected diabetes is evaluated as 20 percent disabling. In July 2008 and June 2010 treatment notes, the Veteran was noted to have a diagnosis for diabetes mellitus. However, on the latter occasion, the examiner did not provide details as to the severity of the Veteran’s diabetes. In June 2011, the Veteran was afforded a VA examination. The Veteran reported following a restricted diet, but he had no restricted activities, and he was taking insulin before meals. The examiner noted that the Veteran’s diabetes was poorly controlled. In a June 2011 VA examination, the Veteran noted two instances of bed wetting prior to starting treatment for diabetes. However, the examiner noted that the Veteran’s bladder problems stopped once he began treatment for diabetes. During the period on appeal, the Veteran’s diabetes mellitus has been characterized by no more than following a restricted diet, no restricted activities, and taking insulin before meals. Given these facts, the preponderance of the evidence is against the claim for a 40 percent rating under Diagnostic Code 7913. A rating of 40 percent is not warranted because the Veteran’s activities are not restricted due to his diabetes. 3. Entitlement to a rating in excess of 10 percent effective December 10, 2009, for left knee laxity Diagnostic Code 5257 provides ratings for recurrent subluxation or lateral instability. Slight disability warrants a 10 percent rating and a moderate disability warrants a 20 percent rating. Severe disability warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2017). In a September 2003 treatment note, the Veteran reported a history of knee pain with a small amount of swelling. The clinician noted normal gait and posture and a normal X-Ray study from December 1998. In a May 2008 X-Ray study, the Veteran’s left knee was noted to have no evidence of fracture or dislocation or other significant abnormality. In a May 2008 treatment note, the Veteran’s left knee was noted to have no lateral instability or buckling. In a June 2011 VA examination, the Veteran noted continuous knee pain and stated that his knee had given out and caused him to fall in some instances. The Veteran also reported that he is unable to participate in sports but can bathe, dress, groom himself, and drive his car. However, stability testing indicated that the Veteran had minimal laxity in his left knee. During the period on appeal, the Veteran’s left knee laxity has been characterized by no more than minimal laxity with normal gait and posture Given these facts, the Board finds that the preponderance of the evidence is against the claim for a rating greater than 10 percent under Diagnostic Code 5257 for the Veteran’s left knee laxity. A rating of 20 percent is not warranted because the Veteran’s left knee laxity is not moderate in severity. 4. Entitlement to a rating in excess of 10 percent effective December 10, 2009, for right and left knee flexion The Board notes that the Veteran’s right knee flexion has been claimed as right knee strain and the Veteran’s left knee flexion has been claimed as left knee iliotibial band syndrome. Both knees have also previously been claimed as bilateral chondromalacia with degenerative osteoarthritis. The Board has combined the analysis for both claims below for expediency and clarity. Diagnostic Code 5003 provides ratings for degenerative arthritis. Degenerative arthritis, established by X-ray, will be rated on the basis of limitation of motion under the appropriate diagnostic criteria for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups; a 20 percent rating is warranted if there are also occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2003). There are also two relevant note provisions associated with Diagnostic Code 5003. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Limitation of flexion to 60 degrees warrants a noncompensable rating. Limitation of flexion to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2017). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59. In a September 2003 treatment note, the Veteran reported a history of knee pain with a small amount of swelling. The clinician noted normal gait and posture and a normal X-Ray study from December 1998. The clinician also stated that the Veteran’s range of motion was normal. In a March 2008 treatment note, the Veteran was noted to have normal range of motion and normal strength in both knees. In a May 2008 X-Ray study, the Veteran’s left knee was noted to have no evidence of fracture or dislocation or other significant abnormality. In a May 2008 treatment note, the Veteran’s left knee was noted to have full range of motion. In a September 2009 service treatment record (STR), the Veteran was noted to have generalized pain in his left knee. In an April 2010 treatment note, the Veteran was noted to have iliotibial band syndrome. In a June 2011 VA examination, the Veteran’s left knee range of motion measurements included flexion from 0 to 115 degrees and extension of 0 degrees. The Veteran’s right knee range of motion measurements included flexion from 0 to 110 degrees and extension of 0 degrees. A July 2011 X-Ray study noted iliotibial band syndrome in the Veteran’s left knee. During the period on appeal, the Veteran’s left knee iliotibial band syndrome has been characterized by no more than pain with motion and range of motion measurements including flexion from 0 to 115 degrees and extension of 0 degrees. During the period on appeal, the Veteran’s right knee strain has been characterized by no more than pain with motion and range of motion measurements including flexion from 0 to 110 degrees and extension of 0 degrees. Given these facts, the Board finds that a rating of 10 percent is warranted under Diagnostic Code 5003 for the Veteran’s right and left knee flexion impairment. The Veteran’s limitation of motion is noncompensable under Diagnostic Code 5260. However, the Veteran is entitled to a 10 percent rating for painful motion under Diagnostic Code 5003. A 10 percent rating is the maximum rating available under Diagnostic Code 5003. A rating of 20 percent under Diagnostic Code 5260 is not warranted because the Veteran’s right and left knee flexion are not limited to 30 degrees. 5. Entitlement to a rating in excess of 10 percent effective December 10, 2009, for right and left ankle strain The Board has combined the analysis of the Veteran’s right and left ankle strains for expediency and clarity below. Diagnostic Code 5271 provides ratings for limited range of motion for the ankle. A 10 percent disability rating is warranted for moderately limited motion and a 20 percent disability rating for marked limited motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271. In a February 2008 treatment note, the Veteran was noted to have swelling in his left ankle but his range of motion was also noted to be normal. In a May 2008 treatment note, the Veteran was noted to have a history of a left ankle strain. In a June 2011 VA examination, the Veteran noted ankle pain and the use of prescribed ankle braces. The clinician noted tenderness in the left ankle. Both ankle range of motion measurements included dorsiflexion from 0 to 10 degrees and plantar flexion from 0 to 35 degrees. During the period on appeal, the Veteran’s right and left ankle strains have been characterized by no more than tenderness in the left ankle. Both ankles exhibited range of motion measurements including dorsiflexion from 0 to 10 degrees and plantar flexion from 0 to 35 degrees. Given these facts, the Board finds that the preponderance of the evidence is against the claims for ratings more than 10 percent under Diagnostic Code 5271 for the Veteran’s right and left ankle strains. A 20 percent rating is not warranted because the Veteran’s range of motion limitations are not “marked.” 6. Entitlement to a rating of 20 percent effective December 10, 2009, for lumbosacral strain Diagnostic Code 5237 provides ratings for lumbosacral strain. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, for the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, for muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, for the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less or for favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5237. There are also several relevant note provisions associated with Diagnostic Code 5237: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Code 5237. In a September 2003 treatment note, the Veteran was noted to have flexion from 0 to 90 degrees, extension from 0 to 30 degrees, right lateral flexion from 0 to 30 degrees, left lateral flexion from 0 to 30 degrees, right lateral rotation from 0 to 30 degrees, and left lateral rotation from 0 to 30 degrees. In an April 2010 treatment note, the Veteran noted a history of low back pain. The clinician did not provide range of motion measurements. In a June 2011 VA examination, the Veteran noted pain radiating to his upper back and avoidance of lifting heavy objects. Upon examination, the clinician noted left lower extremity strength as “3/5” and right left lower extremity as normal. Upon examination, the Veteran’s range of motion measurements included flexion from 0 to 45 degrees, extension from 0 to 20 degrees, right lateral flexion from 0 to 25 degrees, left lateral flexion from 0 to 15 degrees, right lateral rotation from 0 to 40 degrees, and left lateral rotation from 0 to 35 degrees. In a July 2013 statement, the Veteran stated that his range of motion limitations from the June 2011 examination most closely resemble a 20 percent rating for the Veteran’s back. The Veteran cited his limitation of flexion to 45 degrees. During the period on appeal, the Veteran’s lumbosacral strain has been characterized by no more than pain radiating to his upper back, avoidance of lifting heavy objects, and range of motion measurements including flexion from 0 to 45 degrees, extension from 0 to 20 degrees, right lateral flexion from 0 to 25 degrees, left lateral flexion from 0 to 15 degrees, right lateral rotation from 0 to 40 degrees, and left lateral rotation from 0 to 35 degrees. The preponderance of the evidence is against the claim for a rating more than 20 percent under Diagnostic Code 5237 for the Veteran’s lumbosacral strain due to his forward flexion limited to 45 degrees. A 40 percent rating is not warranted because the Veteran does not have forward flexion of 30 degrees or less and there is no evidence of favorable ankylosis of the entire thoracolumbar spine. 7. Entitlement to a compensable rating effective December 10, 2009, for hypertension is denied. Under Diagnostic Code 7101, hypertension warrants a 10 percent evaluation with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent evaluation is warranted when diastolic pressure is predominantly 120 or more. A 60 percent evaluation is warranted when diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran’s blood pressure readings are summarized in the table below: Date: Document type: Blood pressure reading(s) March 2008 Treatment note 133/77 March 2008 Treatment note #2 158/100 April 2008 Treatment note 138/83 May 2008 Treatment note 141/82 May 2008 Treatment note #2 144/82 June 2008 Treatment note 147/86 March 2010 Treatment note 158/97 April 2010 Treatment note 139/87 April 2010 Treatment note #2 144/88 June 2010 Treatment note 150/100 June 2011 Home readings 135/86 - 144/96 (range) June 2011 VA examination 110/80 During the period on appeal, the Veteran’s hypertension has been characterized by no more than blood pressure readings with systolic pressure predominately below 160 and diastolic pressure predominately below 100. Given these facts, the Board finds that the preponderance of the evidence is against the claim for compensable rating for the Veteran’s hypertension under Diagnostic Code 7101. A 10 percent rating is not warranted because the Veteran’s systolic pressure is not predominately above 160 and the Veteran’s diastolic pressure is not predominately above 100. 8. Entitlement to a rating of 20 percent effective December 10, 2009, for left shoulder status post sprain The rating criteria for evaluating disabilities of the shoulder, including Diagnostic Code 5201, distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. See 38 C.F.R. § 4.69. Because the record on appeal establishes that the Veteran is right-handed, the criteria for rating disabilities of the major extremity are for application. Under Diagnostic Code 5201, a 20 percent rating is assigned where motion of either arm is limited to the shoulder level. A 30 percent rating requires that motion of the major arm be limited to midway between the side and shoulder level, and a maximum 40 percent rating requires limitation of motion of the major arm to 25 degrees from the side. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. In determining whether a Veteran has limitation of motion to shoulder level, it is necessary to consider reports of both forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Normal shoulder motion is defined as zero to 180 degrees of forward elevation (flexion), 0 to 180 degrees from the side of the body out to the side (abduction), and zero to 90 degrees of internal and external rotation. See 38 C.F.R. § 4.71, Plate I. In a September 2009 service treatment record (STR), the Veteran was noted to have pain in his right shoulder. In a September 2010 examination, the Veteran’s shoulder was evaluated. The Veteran noted falling off a tank while in service in approximately 1992. The examiner reported symptoms of pain, weakness, stiffness, and fatigability. The Veteran reported inability to lift his left arm above shoulder level during flare-ups. Upon examination, the Veteran’s range of motion measurements included forward flexion to 90 degrees, abduction to 90 degrees, external rotation to 60 degrees, and internal rotation to 30 degrees. The examiner noted no instability in the Veteran’s shoulder. In a June 2011 VA examination, the Veteran’s left shoulder range of motion measurements included flexion from 0 to 60 degrees and abduction from 0 to 70 degrees. The Veteran was unable to perform rotation movements with his left shoulder due to pain. During the period on appeal, the Veteran’s left shoulder, status post sprain has been characterized by no more than inability to lift his left arm above shoulder level during flare-ups. Given these facts, the Board finds that the preponderance of the evidence is against the assignment of rating greater than 20 percent under Diagnostic Code 5201 for the Veteran’s left shoulder range of motion. A 30 percent rating is not warranted because the Veteran can life his arm more than 25 degrees from his side. New and Material Evidence Generally, absent the filing of an NOD within one year of the date of mailing of the notification of the initial review and determination of a veteran’s claim and the subsequent filing of a timely substantive appeal, a rating determination is final and is not subject to revision upon the same factual basis except upon a finding of clear and unmistakable error (CUE). 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 20.200, 20.300, 20.1103. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The provisions of 38 C.F.R. § 3.156(a) create a low threshold, with the phrase “raises a reasonable possibility of substantiating the claim” enabling rather than precluding reopening and not constituting a third requirement that must be met before the claim is reopened. Shade v. Shinseki, 24 Vet. App. 110 (2010); Evans v. Brown, 9 Vet. App 273, 283 (1996). See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Where documents are within VA’s control and could reasonably be expected to be a part of the record, such documents are, in contemplation of law, before VA and should be included in the record. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). In September 2003, the RO denied service connection for a right leg radiculopathy. The Veteran’s right leg radiculopathy claim relied on his service connection claim for a lumbosacral strain. The Veteran was denied service connection for his lumbosacral strain and therefore his claim for right leg radiculopathy was also denied. The Veteran was informed in writing of the adverse decision and his appellate rights in September 2003. He did not submit an NOD. The evidence received prior to the September 2003 rating decision reflects that the Veteran was treated in-service with complaints of back pain. The evidence also indicated that the Veteran was diagnosed with chronic, recurrent lumbosacral strain with right lower extremity radiculopathy. New and material evidence pertaining to the issue of service connection for right leg radiculopathy was not received by VA or constructively in its possession within one year of written notice of the September 2003 rating decision. Therefore, that decision became final. 38 C.F.R. § 3.156(b). The additional documentation received since September 2003 includes an in-service medical examination from April 2008. The Board also notes that the Veteran’s lumbosacral strain is now service-connected. In June 1999, the RO denied the Veteran’s service connection claims for left foot pain, bilateral fallen arches, right wrist sprain, sinusitis, refractive error, and post circumcision residuals. The Veteran was informed in writing of the adverse decision and his appellate rights in June 1999. He did not submit an NOD. In June 1999, the evidence indicated that the Veteran’s left foot pain was reported in-service and diagnosed as a fracture which had since resolved. The additional evidence since June 1999 includes statements from the Veteran indicating that he collided with another soldier in service, complaints of foot pain, an April 2001 in-service examination noting mild plantar fasciitis, an April 2008 in-service examination noting mild pes planus, and an X-Ray study of the Veteran’s left foot from July 2011. In June 1999, the RO also denied the Veteran’s claim to establish service connection for bilateral fallen arches. The evidence indicated that the Veteran did not have complaints or treatment for fallen arches. Additional evidence since June 1999 includes service treatment records with complaints of foot pain, an April 2008 in-service examination noting mild pes planus, and a June 2011 examination in which the Veteran had complaints of intermittent pain in his arches. In June 1999, the RO denied the Veteran’s claim to establish service connection for right wrist pain. The evidence indicated that the Veteran’s right wrist was injured while boxing but that there was no swelling, pain, or limitation of motion and that the Veteran’s right wrist injury had resolved. Additional evidence since June 1999 includes a June 2011 VA examination in which the Veteran reported significant pain in his wrist, aggravated by repetitive activities. In June 1999, the RO denied the Veteran’s claim to establish service connection for sinusitis. The evidence indicated that the Veteran had no problems with his sinuses. Additional evidence since June 1999 includes multiple complaints of sinus related symptoms and a July 2008 treatment note reporting a history of allergic rhinitis. In June 1999, the RO denied the Veteran’s claim to establish service connection for a refractive error. The evidence indicated that the Veteran’s condition was a congenital or developmental defect which was unrelated to military service. Additional evidence since June 1999 includes an August 2005 optometry examination in which the Veteran reported blurry vision, even while wearing glasses and a July 2008 treatment note indicating conjunctivitis in the Veteran’s left eye but no refractive error. In June 1999, the RO denied the Veteran’s claim to establish service connection for post circumcision residuals. The evidence indicated some complaints of pain with walking immediately following the surgery but no permanent disability. Additional evidence since June 1999 includes a June 2011 VA examination which notes the Veteran has a “normal uncircumcised phallus with no deformity.” The Board finds this statement contradictory to the rest of the Veteran’s medical record and has determined that reopening is warranted. When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Here, the newly-submitted evidence is of such significance that, when considered for the limited purpose of reopening the Veteran’s claim, it raises a reasonable possibility of substantiating his claim for service connection when considered with the previous evidence of record. As new and material evidence has been received, the Veteran’s claims for entitlement to service connection for right leg radiculopathy, left foot pain, bilateral fallen arches, right wrist sprain, sinusitis, refractive error, and post circumcision residuals are reopened. In June 1999, the RO also denied the Veteran’s service connection claims for left elbow pain and bilateral shin splints. The Veteran was informed in writing of the adverse decision and his appellate rights in June 1999. He did not submit an NOD. In June 1999, the RO denied the Veteran’s claim to establish service connection for left elbow pain. The evidence indicated that the Veteran did not have a left elbow disability and examinations indicated the Veteran had a normal left elbow with no fractures or dislocations. Additional evidence since June 1999 includes a June 2011 VA examination in which the Veteran reported no symptoms in his left elbow since service separation. In June 1999, the RO denied the Veteran’s claim to establish service connection for bilateral shin splints. The evidence indicated that the Veteran experienced shin splints while in service but the disability had since healed and resolved. Additional evidence since June 1999 includes a June 2011 VA examination. The Veteran indicated that he experienced shin splints in service but had no current symptoms. Here, the newly-submitted evidence is of such significance that, when considered for the limited purpose of reopening the Veteran’s claim, it raises a reasonable possibility of substantiating his claim for service connection when considered with the previous evidence of record. Justus, supra. The Board notes that the new evidence pertaining to the Veteran’s claims to establish service connection for left elbow pain and bilateral shin splints does not raise a reasonable possibility of substantiating his claims for service connection. Therefore, the reopening of these claims is not warranted and the request to reopen is denied. Service Connection Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. Entitlement to service connection for left foot pain The probative and competent evidence of record is against the Veteran’s claim of entitlement to service connection for left foot pain. As noted above, the threshold requirement for service connection to be granted is competent evidence of the current existence of the claimed disorder. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is no medical evidence demonstrating that the Veteran was diagnosed with a separate foot pain disorder during the pendency of the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (service connection may be granted if a disability existed at the time a claim for VA disability compensation was filed or at any time during the pendency of the claim, even if the disability resolves prior to the adjudication of the claim); see Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001) and Sanchez-Benitez v. West, 13 Vet. App. 282 (1999) (service connection may not be granted for symptoms unaccompanied by a diagnosed disability). The Board has considered the Veteran’s in-service complaints of transient foot injuries but notes no evidence indicating a permanent disability. A July 2011 X-Ray indicated the Veteran’s left foot had no fractures or dislocations and his bones and soft tissues were within normal limits. Therefore, service connection is not warranted and the claim is denied. 2. Entitlement to service connection for right wrist sprain In the Veteran’s November 1984 examination for enlistment he was noted to have no relevant health problems and reported that he was in excellent health. In a July 1986 in-service physical, the Veteran was noted to have no relevant health complaints, reported that he was in generally good health. In a September 1997 examination for service separation, the Veteran noted a right wrist sprain from a boxing. In March 2002, December 2003, December 2004, and June 2006 examinations, the Veteran’s PULHES profile indicated that he was in excellent physical health, including as to his upper extremities as indicated by the “U” designator. In a June 2011 VA examination, the Veteran reported significant pain in his right wrist. The Veteran noted that he injured his wrist in a boxing match while in service. The Veteran noted additional pain during heavy or repetitive activities. The examiner noted no evidence of in-service treatment for the Veteran’s right wrist. Upon examination the clinician noted stiffness but no fatigue, weakness, or lack of endurance. In a July 2011 X-Ray study, the Veteran’s wrist was noted to have no fractures or dislocations and was within normal limits. The probative and competent evidence of record is against the Veteran’s claim of entitlement to service connection for right wrist sprain. As noted above, the threshold requirement for service connection to be granted is competent evidence of the current existence of the claimed disorder. Degmetich and Brammer, supra. v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board has considered the Veteran’s complaints of in-service injury to his wrist but notes no ongoing diagnosis for a permanent disability. Therefore, service connection is not warranted and the claim is denied. 3. Entitlement to service connection for sinusitis In service, from January 1990 to March 1997, the Veteran was seen multiple times with complaints of cold symptoms including productive cough, congestions, fever, runny nose, and sore throat. A June 1997 X-Ray study indicated that the Veteran had a normal chest X-Ray. In an April 2001 in-service physical, the Veteran was noted to have normal sinuses and a normal throat and nose. In a September 2003 treatment note, the Veteran was seen with congestion symptoms including nasal discharge, productive cough, and ear pressure. In a June 2006 enlistment medical examination, the Veteran was noted to have no relevant medical complaints and reported that his sinuses were normal. In a July 2008 treatment note, the Veteran was noted to have a history of allergic rhinitis. In an August 2008 STR, the Veteran was noted to have a sore throat that was getting progressively worse. In a June 2011 VA examination, the Veteran reported that he developed sinusitis while in-service. The Veteran noted treatment with antibiotics while in service and stated that he would get approximately one infection per year while in service. The Veteran noted no infections since he got out of the military. The probative and competent evidence of record is against the Veteran’s claim of entitlement to service connection for sinusitis. There is no medical evidence demonstrating that the Veteran was diagnosed with a separate sinus disorder during the pendency of the appeal. McClain and Sanchez-Benitez v. West, supra. The Veteran noted no infections since he left he was discharged from military service in a June 2011 VA examination. The Board has considered various complaints of transient cold like symptoms but no diagnosis of a permanent disability. Therefore, service connection is not warranted and the claim is denied. 4. Entitlement to service connection for refractive error For purposes of entitlement to benefits, the law provides that refractive errors of the eyes are developmental defects and not a disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303 (c), 4.9 (2017). In the absence of a superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. §§ 3.303(c), 4.9. VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90 (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). In the Veteran’s November 1984 examination for enlistment he was noted to have no relevant health problems and reported that he was in excellent health. In a July 1986 in-service physical, the Veteran was noted to have no relevant health complaints, reported that he was in good overall health. In a March 1987 service treatment note, the Veteran had complaints of trouble seeing near and distance and noted headaches in the morning. In the Veteran’s November 1987 examination for enlistment, he was noted to have no relevant health problems and was reported to be in good health. In a September 1993 service treatment note the Veteran noted trouble seeing at a distance and seeing near distance. The Veteran also noted headaches that he felt were induced by eyestrain. In an August 1997 STR, the Veteran reported eye pain, dizziness, and hazy vision. In an April 2001 in-service examination, the Veteran was noted to have normal eyes. In March 2002, December 2003, December 2004, and June 2006 examinations, the Veteran’s PULHES profile indicated that he was in excellent physical health, including as to his eyes as indicated by the “E” designator. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992); ((observing that the “PULHES” profile reflects the overall physical and psychiatric condition of the veteran’s capacity and stamina (“P”); upper extremities (“U”); lower extremities (“L”); hearing (“H “); eyes (“E”) and psychiatric condition (“S”); assessed on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). In an August 2005 optometry examination, the Veteran was noted to have blurry vision even when wearing glasses. In a July 2008 treatment note, the Veteran was noted to have conjunctivitis in his left eye. The clinician also noted no refractive error, cataract, or glaucoma. The Veteran’s distance vision was noted to be 20/20 in both eyes. In a June 2011 VA examination, the Veteran was noted to have reactive pupils, full extraocular movements, and clear sclerae and clear conjunctivas. The preponderance of the probative and competent evidence of record is against the Veteran’s claim of entitlement to service connection for refractive error. There is no competent evidence indicating that the Veteran’s vision disorder is anything but a congenital refractive error. The conjunctivitis noted in the left eye was cleared by June 2011. As noted above, the threshold requirement for service connection to be granted is competent evidence of the current existence of the claimed disorder. Degmetich, above. Therefore, service connection is not warranted and the claim is denied. 5. Entitlement to service connection for left ear hearing loss An organic disease of the nervous system including sensorineural hearing loss is a “chronic disease” listed under 38 C.F.R. § 3.309(a). Therefore, the provisions of 38 C.F.R. § 3.303(b) are for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such during active service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected unless they are clearly attributable to intercurrent causes. Generally, if a condition noted during active service is not shown to be chronic, then, a “continuity of symptoms” after service is required to establish service connection. 38 C.F.R. § 3.303(b). Service connection for impaired hearing shall be established when the thresholds for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz are 40 decibels or more; or the thresholds for at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). In the Veteran’s November 1984 examination for enlistment he was noted to have no relevant health problems and reported that he was in excellent health. In a July 1986 in-service physical, the Veteran was noted to have no relevant health complaints and reported that he was in good overall health. In the Veteran’s November 1987 examination for enlistment, he was noted to have no relevant health problems, and was reported to be in good overall health. In a May 1988 audiogram, the Veteran’s pure tone thresholds, in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- -- -- -- -- LEFT 15 10 00 00 10 In a January 1994 audiogram, the Veteran’s pure tone thresholds, in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- -- -- -- -- LEFT 15 05 05 00 00 In a June 1997 audiogram, the Veteran’s pure tone thresholds, in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- -- -- -- -- LEFT 05 00 00 05 10 In an April 2001 in-service physical, the Veteran was afforded a VA audiological examination. During this examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 5 5 15 LEFT -5 5 0 10 15 In March 2002, December 2003, December 2004, and June 2006 examinations, the Veteran’s PULHES profile indicated that he was in excellent physical health, including as to his hearing and ears, as indicated by the “H” designator. In a June 2006 audiogram, the Veteran’s pure tone thresholds, in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- -- -- -- -- LEFT 00 05 00 00 00 In an April 2008 audiogram, the Veteran’s pure tone thresholds, in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- -- -- -- -- LEFT 00 00 5 -5 0 In a November 2009 audiogram, the Veteran’s pure tone thresholds, in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- -- -- -- -- LEFT 50 50 40 50 50 The Board notes these audiogram results are an anomaly given the multiple audiograms that indicate the Veteran has normal hearing. In a June 2011 VA examination, the Veteran was noted to have normal canals and membranes. In July 2011, the Veteran was afforded a VA audiological examination. During this examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- -- -- -- -- LEFT 15 10 15 5 5 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 100 percent in the left ear. Based on these results, the VA examiner concluded the Veteran did not have bilateral sensorineural hearing loss. The examiner noted normal hearing for all frequencies in both ears. The probative and competent evidence of record is against the Veteran’s claim of entitlement to service connection for left ear hearing loss. As noted above, the threshold requirement for service connection to be granted is competent evidence of the current existence of the claimed disorder. Degmetich, supra. VA examiners have concluded that the Veteran has normal hearing. Therefore, service connection is not warranted and the claim is denied. 6. Entitlement to service connection for a right foot condition In the Veteran’s November 1984 examination for enlistment he was noted to have no relevant health problems and reported that he was in excellent health. In a July 1986 in-service physical, the Veteran was noted to have no relevant health complaints and reported that he was in good overall health. In a December 1993 STR, the Veteran had complaints of right heel pain after a socket wrench hit his heel. The Veteran also reported reinjuring his foot when he was running on rocks. The clinician noted no swelling and no reaction during palpitation and diagnosed a bruised tendon in the Veteran’s heel. In an April 2001 in-service physical, the Veteran noted “foot trouble.” Upon examination the clinician noted mild plantar fasciitis in the Veteran’s left foot. In March 2002, December 2003, December 2004, and June 2006 examinations, the Veteran’s PULHES profile indicated that he was in excellent physical health, including as to his lower extremities as indicated by the “L” designator. In an April 2008 in-service examination, the Veteran noted injuring his right foot in basic training. In a June 2011 VA examination, the Veteran noted spasms in his right foot following a 10-kilometer run and treatment at a clinic while in-service. In a July 2011 X-Ray study, the Veterans right foot was noted to have no fractures or dislocations and the bones and soft tissues were within normal limits. The probative and competent evidence of record is against the Veteran’s claim of entitlement to service connection for a right foot condition. There is no medical evidence demonstrating that the Veteran was diagnosed with a separate right foot disorder during the pendency of the appeal. The Veteran has experienced some acute injuries to his right foot but there is no diagnosis of a permanent condition. Therefore, service connection is not warranted and the claim is denied. 7. Entitlement to service connection for a bladder condition In the Veteran’s November 1984 examination for enlistment he was noted to have no relevant health problems and reported that he was in excellent health. In a July 1986 in-service physical, the Veteran was noted to have no relevant health complaints and reported that he was in good overall health. The Veteran also noted that no bed wetting since July 1986. In the Veteran’s November 1987 examination for enlistment, he was noted to have no relevant health problems and was reported to be in good health. In an April 2001 in-service examination, the Veteran noted no instances of bed wetting since age 12, no blood in his urine, and no pain with urination. In a June 2011 VA examination, the Veteran noted two instances of bed wetting prior to starting treatment for diabetes. The examiner noted that the Veteran’s bladder problems stopped once he began treatment for diabetes. The examiner noted some tenderness over the bladder area but did not provide a diagnosis related to the Veteran’s bladder. The preponderance of the probative and competent evidence of record is against the Veteran’s claim of entitlement to service connection for a bladder condition. There is no medical evidence demonstrating that the Veteran was diagnosed with a separate bladder disorder during the pendency of the appeal. McClain, supra. The Veteran bed wetting resolved after the Veteran began treatment for his diabetes. There is no diagnosis of a permanent bladder condition. Therefore, service connection is not warranted and the claim is denied. 7. Entitlement to service connection for a stomach condition In the Veteran’s November 1984 examination for enlistment he was noted to have no relevant health problems and reported that he was in excellent health. In a July 1986 in-service physical, the Veteran was noted to have no relevant health complaints, reported that he was in good overall health. In the Veteran’s November 1987 examination for enlistment, he was noted to have no relevant health problems and was reported to be in good health. In September 2000, the Veteran was seen with complaints of stomach and chest pain. The Veteran was afforded an X-Ray study which found his chest and lungs to be clear. In an April 2001 in-service examination, the Veteran noted no stomach, liver, or intestinal trouble. In a June 2011 examination, the clinician noted no in-service complaints for a stomach condition. The Veteran reported taking medication for some gastroesophageal reflux like symptoms but reported no current diagnosis. The preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a stomach condition. The Veteran is not diagnosed with a stomach disorder. Service connection is not warranted and the claim is denied. 8. Entitlement to service connection for left leg radiculopathy In an August 1997 STR, the Veteran noted sustaining injuries when he fell off a tank. In a September 2003 treatment note, the Veteran had a normal neurological examination. In an April 2008 in-service medical examination, the Veteran noted numbness and tingling in his legs because of him falling from a tank and injuring his back. In a June 2011 general medical examination, the Veteran noted experiencing sharp pain that radiates down his left leg. The Veteran also noted pain radiating to his upper back and avoidance of lifting heavy objects. Upon examination, the clinician noted left lower extremity strength as “3/5” and right left lower extremity as normal. The Veteran contends that his left leg radiculopathy began because of his low back condition which is service-connected. Upon resolution of all reasonable doubt in the Veteran’s favor, the Board concludes that service connection is warranted for left leg radiculopathy and the claim is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 9. Entitlement to service connection for sleep apnea In an April 2001 in-service examination, the Veteran reported that he did not have frequent trouble sleeping. In a May 2010 treatment note, the Veteran reported difficulty sleeping following his return from deployment in November 2009. The Veteran reported that his wife sometimes shakes him to prevent snoring. The clinician noted a history of primary insomnia. In an examination received in December 2010, the Veteran was noted not to have frequent trouble sleeping. In a June 2011 VA examination, the Veteran noted snoring, gasping for air and some daytime somnolence but not a lot of napping. In a July 2011 sleep study, the Veteran was noted to have mild obstructive sleep apnea. In February 2012, the Veteran was afforded a VA examination. The Veteran reported that he was always tired, does not sleep well, and awakens often. The Veteran noted that a July 2011 sleep study found that the he stopped breathing during sleep and had “a lot of movement” but did not have a diagnosis for sleep apnea. However, the examiner noted a diagnosis for sleep apnea in July 2011. The examiner stated that the Veteran’s sleep apnea is a mechanical condition related to his upper airway and due to his large size and thick neck. The examiner opined that the Veteran’s sleep apnea is not due to the sleep disturbance he experienced while deployed. The Board has considered the Veteran’s claim that his sleep apnea is caused by his military service. The Veteran is not competent, however, to offer an opinion as to the etiology of this type of medical condition due to the medical complexity of the matter involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). A preponderance of the evidence is against a finding that the Veteran’s sleep apnea originated during service. There is no competent medical evidence linking the Veteran’s current sleep apnea diagnosis to his service and the February 2012 VA examiner specifically noted the Veteran’s sleep apnea was due to the Veteran’s large build and not related to his service. Therefore, service connection is not warranted and the claim is denied. REASONS FOR REMAND The Veteran’s claim for a rating more than 10 percent for left middle finger fracture is remanded for further development. The Veteran’s service connection claims for right leg radiculopathy, bilateral fallen arches, post circumcision residuals, left foot pain, right shoulder condition, and left pinky condition are also remanded for further development. The case is REMANDED for the following action: 1. Request that the Veteran provide the names and addresses of all health care providers who provided treatment for his left middle finger fracture, right leg radiculopathy, bilateral fallen arches, post circumcision residuals, left foot pain, right shoulder condition, and left pinky condition. After acquiring this information and obtaining any necessary authorization, obtain and associate any pertinent records with the claims file or e-folder. 2. After all available records have been associated with the claims file and/or e-folder, schedule the Veteran for a VA examination to determine the symptomatology of his left middle finger fracture. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. a. The examiner should provide an opinion as to the current symptomatology and severity of the Veteran’s left middle finger fracture. b. Specifically, the examiner should provide a measurement of the gap between the Veteran’s fingertip and the proximal transverse crease of the palm with the finger flexed to the extent possible and with extension limited by no more than 30 degrees. c. As noted above, the examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In a September 2010 examination, the Veteran’s hand, thumb, and fingers were evaluated. The Veteran noted a left middle finger fracture as the result of playing football in 1995, and a combat tank accident in 2003. The Veteran noted that his fingers sometimes lock. Upon examination, the Veteran was noted to have range of motion measurements including metacarpophalangeal joint to 85 degrees (normal 85 degrees), proximal interphalangeal joint to 90 degrees (normal 110 degrees), and distal interphalangeal joint to 50 degrees (normal 70/80 degrees). The examiner did not provide measurements of the gap between the fingertip and the proximal transverse crease of the palm for rating purposes. 3. After all available records have been associated with the claims file and/or e-folder, schedule the Veteran for a VA examination to determine the etiology of his right leg radiculopathy. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. a. The examiner should provide opinion as to whether the Veteran has a diagnosis for right leg radiculopathy. b. If the examiner determines the Veteran has a diagnosis for right leg radiculopathy he or she should opine as to whether the Veteran’s right leg radiculopathy is related to the Veteran’s service, and specifically, whether the Veteran’s right leg radiculopathy is related to his service-connected lumbosacral strain. c. As noted above, the examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In a September 1989 STR, the Veteran noted pain in his right leg following an injury from playing football. * In a September 2003 treatment note, the Veteran had a normal neurological examination. * In a March 2003 lay statement, the Veteran noted his lower extremity radiculopathy began when he slipped off a tank while in-service. * In an April 2008 in-service medical examination, the Veteran noted numbness and tingling in his legs because of him falling from a tank and injuring his back. 4. After all available records have been associated with the claims file and/or e-folder, schedule the Veteran for a VA examination to determine the etiology of his bilateral fallen arches. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. a. The examiner should provide an opinion as to whether the Veteran has a diagnosis for bilateral fallen arches. b. If the examiner determines the Veteran has a diagnosis for bilateral fallen arches, he or she should provide an opinion as to whether the Veteran’s disability began as a result of his service. c. As noted above, the examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In a June 2006 reserve medical examination, the Veteran was noted to have normal arches. * In an April 2008 medical examination, the Veteran was noted to have mild pes planus. * In a September 2009 STR, the Veteran was noted to have pain in his feet. * In a June 2011 VA examination, the Veteran reported intermittent pain in the arches of his feet. The Veteran noted avoiding walking and lifting or carrying heavy objects. 5. After all available records have been associated with the claims file and/or e-folder, schedule the Veteran for a VA examination to determine the etiology of his post circumcision residuals. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. a. The examiner should provide an opinion as to whether the Veteran has residuals because of his in-service circumcision. b. As noted above, the examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In a June 1997 STR, the Veteran was noted to request a circumcision due to hygiene concerns. * In an August 1997 STR, the Veteran had a follow up visit following his circumcision. The clinician noted pain with walking and bending but no pain with urination. * In a June 2011 VA examination, the Veteran was noted to have a normal uncircumcised phallus with no deformity. The Board notes that this opinion is inconsistent with the rest of the Veteran’s record which indicates the Veteran was circumcised while in service. 6. After all available records have been associated with the claims file and/or e-folder, schedule the Veteran for a VA examination to determine the etiology of his left foot pain. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. a. The examiner should provide an opinion as to whether the Veteran has a diagnosis for a disability in his left foot. Specifically, the examiner should opine as to whether the Veteran has a diagnosis of plantar fasciitis b. If the examiner determines the Veteran has a diagnosis for plantar fasciitis or any other left foot disability, the examiner should provide an opinion as to whether the Veteran’s disability began because of service. c. As noted above, the examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In a September 1991 STR, the Veteran was seen with complaints of left foot pain. The Veteran noted injuring his foot approximately two weeks preceding the treatment but could not recall how he injured his foot. The clinician noted heel pain and assessed the injury as a possible bruise. * In an April 2001 in-service physical, the Veteran noted foot trouble. The examiner noted mild plantar fasciitis in the Veteran’s left foot. * In a June 2011 VA examination, the Veteran reported colliding with another soldier during PT and landing on his left foot. The Veteran noted that he was treated in a clinic. * A July 2011 X-Ray study indicated that the Veteran’s left foot had no fractures or dislocations and his bones and soft tissues were within normal limits. 7. After all available records have been associated with the claims file and/or e-folder, schedule the Veteran for a VA examination to determine the etiology of his right shoulder condition. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. a. The examiner should provide an opinion as to whether the Veteran has a diagnosis for a disability in his right shoulder. b. If the examiner determines the Veteran has a diagnosis for a right shoulder disability, the examiner should provide an opinion as to whether the Veteran’s disability began because of his service. c. As noted above, the examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In a September 2010 shoulder examination, the Veteran reported that he sometimes has difficulty lifting his right arm but did not describe his limitation of motion in detail or the reason for his injury. The Board notes that the examination was focused on the Veteran’s left shoulder symptomatology. * In a June 2011 examination the Veteran reported continuous shoulder pain and noted injuring his right shoulder in service but did not provide details. The clinician noted in-service treatment for both of the Veteran’s shoulders. 8. After all available records have been associated with the claims file and/or e-folder, schedule the Veteran for a VA examination to determine the etiology of his left pinky condition. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. a. The examiner should provide an opinion as to whether the Veteran has a diagnosis for a disability associated with his left pinky. Specifically, the examiner should provide an opinion as to whether the Veteran has a diagnosis for flexion contracture of his pinky finger in the left hand. b. If the examiner determines the Veteran has a diagnosis for flexion contracture or any other left pinky disability, he or she should provide an opinion as to whether the Veteran’s disability began because of service. c. As noted above, the examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In a September 2010 examination, the Veteran reported that his left pinky was injured in 1995 while playing flag football and in a 2003 combat tank accident. The Veteran reported that his pinky sticks up inadvertently, gets caught, and has diminished strength. The examiner noted a diagnosis of flexion contracture in the fifth finger (pinky) of the left hand. (Continued on the next page)   9. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative must be provided with a Supplemental Statement of the Case (SSOC) and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Joshua Wozniak